Healthcare Provider Details

I. General information

NPI: 1780688523
Provider Name (Legal Business Name): ROGER W MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 EXCHANGE ST SUITE #201
ASTORIA OR
97103-3417
US

IV. Provider business mailing address

2095 EXCHANGE ST SUITE #201
ASTORIA OR
97103-3417
US

V. Phone/Fax

Practice location:
  • Phone: 503-338-4455
  • Fax: 503-338-4837
Mailing address:
  • Phone: 503-338-4455
  • Fax: 503-338-4837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD24790
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: